Expertise in psychotherapy is difficult to define

February 26, 2014
by Mike Krings

It has been said that psychotherapy is a field in which expertise does not exist. A University of Kansas professor has co-authored an article stating that while the concept has validity, there are ways psychotherapists, even the best, can improve.

James W. Lichtenberg, professor of psychology and research in education, and colleagues argue in their article that there are many psychotherapists who are very good at what they do, but that expertise is very difficult to define in regards to the field. The problem is exacerbated by a lack of tangible feedback for practitioners and specific opportunities to improve.

"There are those whom we believe are great therapists," Lichtenberg said. "They've written books and are well-recognized by their peers and patients. There are also those that are very highly competent and others still who are good, but their patients don't tend to get better."

Expertise in psychotherapy has generally been measured by a practitioner's reputation, performance or client outcomes. The researchers argue that each is valuable but flawed. The paper, published in the journal American Psychologist, was co-authored by Terence J.G. Tracey of Arizona State University; Bruce E. Wampold of the University of Wisconsin-Madison; and Rodney K. Goodyear of the University of Houston and University of Redlands.

It is generally accepted that in psychotherapy, as in many professions, as one gains experience they improve at the job. While that is likely true for some, simply gaining longevity in the job may do little more than help build a reputation if it isn't accompanied by concrete feedback on one's performance. That lack of feedback is one of the biggest factors preventing true expertise in psychotherapy, the authors argue. Many patients will discontinue treatment without citing a reason. As a consequence, therapists may never learn what they did right or wrong with those clients.

When psychotherapists do get client feedback, it is often sought with hindsight bias, what Lichtenberg compared to "Monday morning quarterbacking," or seeking feedback that confirms preconceived notions.

"I think we tend to look back for information from our clients that confirms our beliefs, instead of looking for information that challenges or tests those beliefs," Lichtenberg said.

People tend to believe they are better at their profession than they truly are, and that is no different for psychotherapy. Previous research has shown that 25 percent of clinicians consider themselves to be in the top 10 percent of the field and that none rate themselves as below average.

Education is key to improvement in many fields. Most licensing boards require psychotherapists to take part in continuing education to maintain their license. However, there is little evidence to support that practitioners are choosing valuable courses that truly help them continue to develop their skills, the authors argue.

Despite the challenges to define and develop expertise, Lichtenberg and colleagues recommend several methods for continued improvement throughout one's career.

Seeking feedback on client progress is crucial, the researchers argue. By measuring a client's trajectory during therapy and comparing it to the normative trajectories of patients from a large sample, therapists can get a clear picture of whether a patient is truly improving. The practice is viable as there are increasingly reliable benchmarks for various disorders. While that measure will help, the authors also suggest taking a disconfirmatory approach, like that commonly used in the physical sciences. By seeking to disconfirm what one believes instead of looking for evidence to confirm previously held beliefs, therapists will get a more accurate confirmation of whether or not their practices are truly helping clients.

Finally, developing and testing clinical hypotheses about one's clients is among the most valuable steps a psychotherapist can take in improving their abilities. By continuing to reflect on their abilities throughout a career and adopting a scientific approach to doing so, psychotherapists can gain expertise, the authors wrote.

"Although it is not difficult to proffer hypotheses—indeed, it is done frequently—a key requirement is that the hypotheses be embedded in a clearly articulated model of client processing and behavior… It is this generation of specific hypotheses, confirmed by experience in deliberate practice, that, we believe, forms the basis of the development of psychotherapeutic expertise."

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